Troy State University

_______________________________________________

(Department Name)

Instructor of Record Form

The Center for Continuing Education at Troy State University requires

a completed Instructor of Record Form on file before the first date the

course/workshop meets. Please complete and return to the Center

for Continuing Education.

___Dr. ___Ms.

___Mr. ___Mrs.

First Name M.I. Last Name

Address

SS#

Work Phone Home Phone

FAX # E-mail Address

Areas of Expertise (optional).

If appropriate, include grade level and a brief abstract for each topic listed. You may

wish to include additional sheets to describe your program topic.

Please mail or fax this completed form and any other information to

Center for Continuing Education

Wendell Mitchell Hall

Troy State University

Troy, Alabama 36082

FAX: 334-670-3621